News From ACFAS

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The payment deadline for all Fellow and Associate ACFAS membership dues is December 31, 2014. Don't let your ACFAS membership slip through the cracks; renew your membership today by visiting acfas.org/paymydues or via mail or fax to ensure your member benefits will continue. All ACFAS Fellow and Associate Members should have received their 2015 ACFAS dues reminders in the mail. If you have questions or need another statement, please contact Terry Wilkinson in the Membership Department. No need to search online for the best Phoenix hotel for the Annual Scientific Conference—ACFAS and onPeak, our official housing partner, have you covered! Book your hotel reservations today through OnPeak or call them at (800) 950-5542.

Plus, if you plan to arrive in Phoenix early or want to extend your stay and your desired room block is no longer available online for the dates you select, contact onPeak. Their reservation specialists can help make arrangements for rooms in the conference hotels so you can stay with your colleagues and still receive the best rates.

Hotels Included in ACFAS Block:
• Sheraton Phoenix Downtown (0.2 miles from convention center)
• Renaissance by Marriott (0.3 miles from convention center)
• Springhill Suites (0.5 miles from convention center)
• Holiday Inn Express (0.6 miles from convention center)
• Hotel Palomar (0.7 miles from convention center) Last Friday, ACFAS eligible voting members received an email from the College’s independent election firm with a unique link to the 2015 Board of Directors Election website. If you are a Fellow, Associate, Life or Emeritus member, please take a few minutes to cast your vote for your elected leadership. Your vote is important to advancing our profession and surgical specialty.

If you haven’t voted yet, two more reminder emails will be sent to you in the next few weeks. If you do not have a valid email address on file with the College, watch your US mail for voting instructions. Voting remains open until January 6, 2015.
Are you a Residency Director planning to attend the 2015 Annual Scientific Conference in Phoenix? Extend your stay to attend the first-ever preconference Residency Directors Forum set for Wednesday, February 18 from 1:30–5:30 pm at the Phoenix Convention Center. This invitation-only event will cover topics to demystify the required components of the CPME approval process. Space is limited and there will be no onsite registration, so register today. The deadline to register is February 6, 2015.

More details regarding the schedule and speakers can be found at acfas.org.

Foot and Ankle Surgery

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A recent study examined the safety and effectiveness of using an external fixator during reconstructive surgery of Charcot feet, a challenging procedure for which little data is available about long-term outcomes. The study involved 292 Charcot feet, all of which were treated surgically using an external fixator for six to eight weeks with offloading. After the fixator was removed, a customized ankle-foot orthosis with full weight bearing was applied for an additional 11 months. Patients also received customized orthopaedic shoes after one year. After an average follow-up period of 24.1 months, all patients experienced improvements of more than one level in their Hoffer activity level scores for lower limb amputees, a significant increase. There were very few severe complications, while the most common minor complication was persistent or recurrent ulceration, which was seen in 67 feet. In addition, secondary amputation was required for just 6.1 percent of the 282 participants, all of whom were at high risk for such amputations. The study concluded that the use of an external fixator during reconstructive surgery of Charcot feet is safe and effective because all extraneous material is removed after six weeks. This in turn eliminates the risk of complications associated with broken screws or plates, the authors noted.


Unilateral tibiotalocalcaneal arthrodesis with an intramedullary nail results in significant improvements in ambulatory function in patients with severe ankle and hindfoot arthritis, a recent study concludes. After an average follow-up period of 17 months, the 21 patients who participated in the study displayed significant improvements in cadence, walking speed and ankle moment of the treated limb. Significant improvements in gait symmetry were also observed, as was a decrease in total support time. Ankle power in the contralateral limb also increased significantly. Sagittal ankle plane motion increased from 22.2 degrees pre-operatively to 24.1 degrees post-operatively in this limb as well. However, sagittal plane ankle motion in the treated limb declined slightly from 13.2 degrees before surgery to 10.2 at final follow-up.

Practice Management

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Experts say that as the year draws to a close, physicians' practices should take several steps to prepare themselves financially for the 2015 tax season. For example, cash-based practices may want to consider giving year-end bonuses to physicians and other staffers. Doing so can be beneficial from a tax perspective because bonuses are tax deductible, says practice administrator Lee Ann Webster, MA, CPA, FACMPE. Physicians' practices can also reduce their taxes by maximizing year end cash expenditures on items such as medical and office supplies and facility repairs, although Webster warns that practices should be sure they have some cash on hand when 2015 begins. Another useful exercise, Webster says, is for practices to review their income and cash flow at the end of the year and use these assessments as the basis for 2015 income and cash flow projections. However, Webster says physicians' practices should not simply assume that their 2015 income and cash flow will be the same as they were in 2014 since variables such as Medicare fee schedules and volume can have significant effects on cash collections. Physicians' practices should be sure to take these changing factors into account when making their projections for the coming year, Webster says.


Physicians' practices should run several types of billing reports at different frequencies to stay on top of any payments they are owed, writes P.J. Cloud-Moulds, who provides financial consulting services to physicians in private practice. For example, practices should run reports each day that provide information about rolling accounts receivable at 0-30, 30-60, 60-90, 90-120 and 120 or more days. Cloud-Moulds says such reports are useful because they show whether the practice's billing department is posting aged accounts receivable as well as if it is following up on denials. Cloud-Moulds says practices should also run a report on Medicare payments each day. This report will help practices identify when they stopped receiving payments from Medicare. Providing this data to Medicare after payments have stopped makes it more likely that the practice will receive all the money it is owed by the government, Cloud-Moulds says. Each week, practices should run reports from their electronic health records program to see if any medical notes and charges are missing. Cloud-Moulds says such reports can play an important role in helping practices get reimbursed for the care they provide. These and other basic billing reports should also be run annually so practices can determine how they are meeting their goals and whether their performance has improved over the last year, Cloud-Moulds says.


John Squire, the president and COO of the electronic health records (EHRs) technology provider Amazing Charts, says EHRs can actually improve interaction between physicians and patients if used correctly. While EHRs have often been blamed for hurting interactions between physicians and patients, since the use of EHRs often forces doctors to look at computer screens more than patients during visits, the use of patient portals in conjunction with EHRs opens up a new communications channel that can help improve patient engagement. Squire points out that this is because patient portals can be used for functions such as sending reminders about preventative or follow-up care, receiving questions and requests from patients and scheduling or changing appointments. EHRs can also improve patient engagement if they are used along with speech recognition software, which can allow physicians to create patient records quickly and more accurately and give them more time to spend with their patients, Squire says. Laboratory, radiology and medical device interfaces, meanwhile, can also help physicians work more efficiently and give patients easy access to test results. Finally, Squire says EHRs can facilitate greater collaboration between doctors and patients when making healthcare decisions. This can be accomplished by physicians demonstrating how an EHR's clinical decision tools work and by reviewing education materials often provided with EHRs.

Health Policy and Reimbursement

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The U.S. House of Representatives could vote as early as Dec. 11 on a bipartisan spending bill that would fund most of the government through the remainder of the fiscal year, Speaker John Boehner says. The $1.1 trillion spending bill does not include language previously inserted into a House measure that would prohibit the Internal Revenue Service from working to implement the Affordable Care Act. The measure also increases funding for the National Institutes of Health by $150 million. The bill has the support of Senate Appropriations Committee Chair Barbara Mikulski (D-Md.), who urged her fellow Democrats to also vote for the measure. Mikulski praised the bipartisan nature of the bill, saying lawmakers reached "across the aisle and across the dome" to create "compromise without capitulation." However, House Minority Leader Nancy Pelosi (D-Calif.) was non-committal, noting that she was simply "hopeful" she could support the bill.


Americans spent $2.9 trillion on healthcare in 2013, up just 3.6 percent from the amount spent in 2012, according to an estimate produced by federal officials that was published by the journal Health Affairs. That was the slowest growth in healthcare spending since 1960 and was the result of factors such as cuts to Medicare spending, slow growth in private health insurance spending due to the growing popularity of high-deductible plans and the large number of consumers who still lack health insurance. Medicare spending cuts contained in the Affordable Care Act and the sequester helped slow the increase in Medicare spending from 4 percent in 2012 to 3.4 percent in 2013. Despite last year's slowdown in healthcare spending, some say that spending will begin to rise following an effort scheduled to begin in January to bring down the number of uninsured consumers. However, indicators of spending for this year have been mixed. Major hospital chains, particularly those in states that have expanded Medicaid, say they are seeing fewer uninsured patients and are realizing higher profits. U.S. health spending growth fell below 4 percent in 2009 with the recession that stripped private health insurance from millions of individuals. But newly revised numbers show an acceleration in 2012 to 4.1 percent before a slump last year.


Although the repeal of Medicare's Sustainable Growth Rate (SGR) formula is thought to be unlikely to occur in the lame-duck session of the current Congress, the next Congress may take up the issue in some way. For example, the new chairs of the congressional committees that oversee Medicare may want to renegotiate the SGR Repeal and Medicare Provider Payment Modernization Act of 2014. That bill passed both houses with support from lawmakers of both parties, although it was scuttled over disagreements about how to pay for the repeal of SGR. Lawmakers could also opt to to include SGR reform in a budget reconciliation bill that could be passed next year.


Few of the 34 states that use Healthcare.gov to enroll consumers in health insurance coverage are taking steps to establish their own exchanges, even though the U.S. Supreme Court could rule in King v. Burwell that federal subsidies are no longer available to their citizens. The only two states that have moved toward creating their own exchanges are Illinois and Arkansas, and the effort to create such an exchange in the latter could be throttled by the state's new Republican governor. Families USA Director Ron Pollack says the inaction is due to the widespread belief among officials in these 34 states that the Supreme Court will not rule that the subsides are only available to consumers who purchase coverage through state-run exchanges, as the plaintiffs in King v. Burwell claim. As a result, these officials generally believe there is no need to build a new exchange. However, the Supreme Court could produce a ruling in which state-partnership exchanges--or those that rely on Healthcare.gov for enrollments while the state handles other aspects of the exchange--may be considered state-run exchanges. Such exchanges are used by seven states, including Illinois.


HealthCare.gov's health insurance exchange for small businesses, the Small Business Health Options Program (SHOP), was unveiled for the first time on Nov. 15 but data released by the Centers for Medicare and Medicaid Services (CMS) indicates that there may be little interest in the program. CMS says there were 200,000 visits to the SHOP section on HealthCare.gov during the week of Nov. 15 to Nov. 22, which is the first week health insurance plans were available on the site. By comparison, more than 1.5 million people browsed health plans for individuals on HealthCare.gov during the same period of time. SHOP has experienced some technical problems, including a still uncorrected flaw that does not give small businesses the option of requiring new employees to wait 90 days before purchasing coverage through the marketplace as they are allowed to do under the Affordable Care Act. Instead, SHOP gives such businesses the option of requiring new employees to wait a maximum of 60 days. Insurance brokers and others also say that SHOP's main selling point has been undermined in part by the Obama administration's decision to postpone the enforcement of a requirement that small businesses be allowed to choose from a variety of insurance plans offered in their area. The Obama administration, for its part, says it is encouraged by data that shows that the number of health insurance plans offered through SHOP has increased since last year, when plans were offered through the program but could not be purchased online.

Medicine, Drugs and Devices

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A new study has concluded that magnetic resonance imaging (MRI) of the deep aspect of the deltoid ligament during the evaluation of ankle mortise stability in patients with supination-external rotation-type lateral malleolar fractures with no widening of the medial clear space is not an effective way to determine how these patients should be treated. The stability of the ankle mortise of the 61 participating patients was assessed using an external-rotation stress test, and an MRI was performed on the anterior and posterior parts of the deep deltoid ligament. These parts of the ligament were then graded by two musculoskeletal radiologists as normal, edematous and partial or complete tear. The study found that interobserver agreement for the stress test was excellent at 94 percent. Interobserver reliability for the MRI assessments was 72 percent for the posterior part of the ligament and 56 percent for the anterior part, both of which reliability measures were fair to moderate. The stress test showed 33 patients as having a medial clear space of 5 mm or more, while MRIs showed that five of these patients had an edematous ligament, 26 had a partial tear and two had a total tear. Among the 28 patients with a medial clear space of less than 5 mm, MRIs showed that nine had an edematous ligament while 19 had a partial tear. Medial clear space increased in tandem with the severity of the deep deltoid ligament injury as indicated by MRI.


Combining dry needling with percutaneous hydrostatic decompression to target both the inside and outside of the Achilles tendon in isolation is an effective way to treat chronic Achilles tendinopathy, the management of which can be difficult, a new study has found. The study found that the 19 patients (24 tendons) who were treated using this method displayed significant improvements in Visual Analog Scores at rest and during activity. Interviews with patients showed that more than 75 percent were highly satisfied with the results of the procedure after 12 to 24 months, while more than 50 percent reported that their symptoms were completely gone. More than 85 percent reported being able to return to playing sports after this period of time. The study found that the procedure was also well-tolerated.